Quiet Professionals, Noisy Machinery

A VA Roundup

Ah, the Veterans Administration. Few things are more dependable, for certain values of dependable: it is a veritable Old Faithful of scandal and all the naughty -feasances. The Department of Veterans Affairs always produces more bleak news than a scandal-weary public can consume.

This post could have been double the size, with treble the specific entries, and we last covered VA problems Friday.

ITEM: What Medical License?

This is from someone known to the blog. Her Grandfather is being treated by a VAMC (Philadelphia) and ran into problems with a specific physician. He insisted Gramps go to dialysis, something she (with a medical background we won’t specify) thinks is unnecessary. This led to a disagreement with him doing the MD equivalent of pointing at the rank on his collar.

So she looked up his board certification. What board certification? He didn’t have any, even in his specialty (which wasn’t nephrology). That’s not that big a deal, we argued: lots of good doctors aren’t board certified, even though there’s been a push for it for decades.

Then she looked up his medical license. What medical license? It turned out (if we have the story straight), the story was that had had one, but not in Pennsylvania; in any event, his license half a continent away had lapsed. But that story was not true: Dr. Dialynsist appears never to have had a license whatsoever.

It is not a requirement at the VA and at some other .gov medical jobs.

He didn’t have one of these. Us neither, but then, we’re not seeing his patients.

Dr. Dialynsist did, in fact, complete medical school (and unlike several of his Philly VAMC Colleagues who are products of Monterrey, Grenada, or Santo Domingo, he did it in the United States!) but he never served an internship or residence. VA classes him as a “fellow,” and roughly like a PA or a nurse practitioner, he’s only supposed to be practicing under the direct supervision of a licensed MD.

The situation is more complex and involved than that. But here’s whee we see a glimmer of light. The lady in question left a long voicemail for the head doc of the center, expecting the usual VA stonewall. Imagine her surprise when she got a call back with an apology for delay — Doc had had a rough period on call, and this was his one day off before things started up again.

He listened. He asked questions. He talked. He explained.

He promised that Dr Dialynsist will be “removed” from the position he’s in. Exactly what that entails, we’re not sure. And that he will take a personal interest in the health of her Grandfather. And he convinced her he means it.

Now, the old veteran is an old man, with an old man’s ills. (Although not, yet, kidney failure). The long-run prognosis for him is the same as the long-run prognosis that that notable physician, Lord Keynes, assigned to all of us: in the long run, we are all dead. But she, at least, is convinced that someone at VA cares about her family member, even though she previously had face time with a guy that visibly did not.

There are good people in the system. There are even good people who haven’t burned out yet (which is as fine a testament to human resilience as there ever was). There’s just always a strong correlation between socialized systems’ disruption of incentives, and bad luck.

ITEM: Suuure, The VA is All on the Up-and-Up.

Dateline, Cleveland, 24 August:

A Buffalo-based company has agreed to pay a $12 million penalty and to divest itself from a large federal project in California to resolve criminal liability from a kickback scheme for which the former Cleveland Veterans Affairs director was sent to prison.

Cannon Design, in an agreement announced Wednesday by the Justice Department and the Department of Veterans Affairs, admitted to criminal conduct by more than a dozen of its employees who took part in the scheme.

The sweetheart deal, cut by the cronies with VA IG Michael Missal, lets all 12 of the admitted criminals avoid charges and consequences: only the company’s stockholders will take the hit, along with one executive, Mark Farmer, who got two years something for bribing a VA official. (The company has to divest itself of only one ill-gotten VA project. It keeps anything else).

Morgantown FCI — the minimum security country club for 800 “connected” Federal inmates.

ITEM: The Union Won the Civil War in 1865. But Against Whom? It Erases the Losers from History.

The Washington Times reports today:

The Veterans Affairs Department quietly moved this month to ban flying of Confederate flags from fixed flagpoles at the cemeteries it runs, striking yet another blow against the controversial emblem.

Congress had debated and rejected that change, but the Obama administration decided to move forward anyway, saying it was unilaterally imposing the restrictions.

“In particular, we will amend our policy to make clear that Confederal flags will not be displayed from any permanently fixed flagpole in a national cemetery at any time,” wrote Ronald E. Walters, under secretary for memorial affairs at the VA.

Walters was writing to an individual Congressman, Administration ally Jared Huffman (D-CA), who has sought such a ban, but could not win a majority for it in his house. Emboldened by the victory, he is now free to seek the desecration of Confederate graves in national cemeteries, long an objective.

Like most Washington nabobs, Jared Huffman himself never served in the military of the United States. No ancestor of Rep. Huffman fought in the Civil War.

The VA has politicized the cemeteries of our fallen soldiers — and their honorable opponents. Is it time to disband it yet, and put this sacred ground under apolitical administration?

ITEM: Wisconsin DVA is Channeling the Fed Version. This is Not Good.

The Wisconsin DVA allegedly has been sticking its fingers into the trust fund of a separate establishment, the King Veterans Home, for its near-$40 million surplus, to support general WDVA operations, according to one WI politician.

State Senator Dave Hansen, D-Green Bay, is calling for a federal investigation of mismanagement and a ban on any future transfers of funds from the King Veterans Home to the Veterans Trust Fund or any other state fund.

[R]esidents, staff and family members have reported severe nursing and staff shortages, broken wheelchairs, urine soaked carpet and have raised the possibility that residents are being overly medicated.

“We have veterans who served in Special Forces saying they were treated like cattle and like children,” Hansen said in the press release. “Such treatment is disrespectful and these claims deserve immediate investigation by no less than the federal government. Until that happens not one dime should be used for any purpose other than fixing the problems at King.”

We’re not personally aware of any SF vets at King, but we don’t know the whereabouts of all our tens of thousands of brothers, so there could be a couple in there. Hansen doesn’t seem like he’s asking anything unreasonable. The WDVA has released a statement that does not seem to be directly responsive to Hansen’s points. It cites US DVA approval of the facilities at King (which is a bit like lobbying Yad Vashem for a medal with Josef Mengele as your character reference).

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5 thoughts on “A VA Roundup”

>Dr. Dialynsist did, in fact, complete medical school […] in the United States […] but he never served an internship or residence. VA classes him as a “fellow,” and roughly like a PA or a nurse practitioner, he’s only supposed to be practicing under the direct supervision of a licensed MD.

First off, this guy sounds like a jerk, and an insecure one at that. Second, we probably need to clarify some terminology to figure out what is going on with Dialysis Guy, “DG”. (Now, a potential confounder is that some fellowship positions are non-clinical and open to PhDs or the like, but in general such do not involve patient contact. Here we will assume that “fellow” refers to a physician-type MD or DO clinical fellow, and ignore the PhD/research fellows.)
TERMINOLOGY: In general, a fellow is a physician doing subspecialty advanced training, meaning that they’ve already completed an internship and residency. (If DG had never done residency, then he might be a research fellow dragooned into clinic for one morning a week or something. But that would be IMO wrong, because the diploma does not make you a physician, the training does. Put it this way: A day-one intern with sheepskin is a dangerous medical student, not a physician. So if DG never did residency, he’s just a jumped up medical student.)
LICENSURE: A physician may have a full or unrestricted license, or a limited/training license (exact words differ from state to state). Anyone in a regular clinical fellowship has already exceeded the training requirements for a general full license, else they would not have been able to get into fellowship. While it would be eccentric for a fellow to work under a training license (i.e. to have not applied for a full license), it is not unheard of. That said, most fellows have a full license, because that allows them to moonlight. (Moonlight: to work a clinical job outside of the official fellowship position for extra money.) So a fellow is NOT like an NP or PA, in that in some circumstances/roles, the person whose “day job” is fellow is fully independent and like any other “regular” physician — no one needs to co-sign or supervise the fellow’s work in their moonlighting job, whereas an NP or PA is always theoretically under MD (or DO) supervision.
Note also that competitive fellowships (GI – gastrointestinal in this context ;-) and cardiology under Internal Medicine, for example) are exactly that, competitive, and a GI or cards fellow is likely to have been near the top of their residency classes to have gotten into fellowship. So between a recently-graduated 31-yo general internal medicine doctor just done with training and now a “real” doctor, and a 31-yo GI fellow, the latter while still a trainee, probably had better grades, board scores and clinical evaluations than the “real” doctor, and may actually be better at general doctoring, at least at that stage. (The generalist, after 10 additional years in practice, will be way better than general doctoring than the subspecialist.)
Back to DG. I am glad to hear that your friend got a solid response from the head doc at the VA. First, if DG was without a license, that was criminal and needed to be stopped immediately from a legal and ethical standpoint. Second, it is possible that DG was a known problem, but no one had complained enough to give his higher ups something actionable to work with. (I had personal experience of this as a family member at a hospice where the attending physician, a geriatrician, was clearly overwhelmed, defensively hostile, and ultimately petty and vindictive. And took it out on the patients. I politely raised holy hell with TPTB. Geri-doc was pulled from the case and an alternate doc found. Family member died and I thought that was that. Well, I happened to visit the facility months later, and a high-up suit intercepted me in the hallway. I thought it was going to be some unpleasantness because I had raised quite a stink, but she thanked me for documenting everything, “We were unhappy with [redacted], but no family member* was willing to speak up and be able to provide details. You gave us the catalyst we needed to take action.”

Mike, thanks for the professional view. As you probably figured out, the whole story was filtered through multiple non-physicians (last of whom was me) before winding up on the blog, and naturally we made a complete botch of the terms.

Licensure was traditionally not required in military hospitals. About 1982 there were several interlocking scandals involving guys who’d lost licenses (for all the reasons an MD might lose his license) and been shuffled from hospital to hospital, with a trail of malpractice judgments behind them. (GI’s can’t sue, but in those days, hospitals, especially overseas, treated dependents too, and dependents can and did sue). In fact, it was when some bright spark pointed out that the cost of the malpractice judgments far exceeded the savings on crap doctors that they began (1) requiring a license from some state (not necessarily the one you’re working in) and (2) firing some of the barbers.

Your insight about the guy who needed to be “documented” rings true to anyone who’s ever worked in the .gov or .mil (or, probably, any large organization) and I’ll pass it on to this lady who’s fighting in her Grandpa’s best interests. She’s very pleased with the response from the VA so far.

About 15 years ago one of my uncles went through the process of getting a VA headstone for an ancestor (his great-grandfather, my great-great). Said ancestor was a veteran. He had been a cavalry trooper in the Confederate army. I am in Kentucky, so a lot of CSA graves around. And flags. Probably not done now. Actually I am surprised the stone hasn’t been repossessed under the current foolishness.

…or hanging in a gas station forecourt, like Benito Mussolina, Clara Petacci, and gang.

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